The reviewer, XXX , chose an article entitled “Randomized Controlled Trial of Yoga among a Multiethnic Sample of Breast Cancer Patients:

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The reviewer, XXX , chose an article entitled “Randomized Controlled Trial of Yoga among a Multiethnic Sample of Breast Cancer Patients: Effects on Quality of Life” which was published in the Journal of Clinical Oncology. The reviewer thoroughly explained how the introduction section of the paper built logical case to provide context for the problem statement. The problem statement was that it is not known whether yoga could improve the quality of life (QoL) of minority population (i.e. African American, Hispanic) who survived from cancer although yoga has been examined to enrich QoL in other individuals (i.e. groups of varying educational and ethnic backgrounds) both with and without cancer. It was pointed out by the reviewer that the reviewer failed to provide an explicit conceptual framework and a hypothesis statement. Elements in group 1 of the checklist of review criteria was well investigated; however, it might have been better if the reviewer included the statement why this article has been selected.

            As mentioned by the reviewer, the literature review was related to the construct of interest and up-to-date; however, it was not comprehensive as the author failed to include the background information regarding minority population. The argument, the need of the study, could have been more persuasive if the author included why more attention is needed to this population and what makes it difficult for them to participate in interventions.

            The aim of the reviewed article was to examine the impact of yoga on quality of life of minority population which is clearly relevant to the aims and scope of the journal, Journal of Clinical Oncology, which focus on breast cancer, molecular oncology, supportive care and quality of life issues. The reviewer mentioned about the generalizability and replicability of the study based on the selection of participants, setting, and measures (QoL). The fact that other minority populations (i.e. Asian American, Pacific Islander, Native American, etc.) were not included was pointed out by the reviewer. This is important because not including other minority groups could lead to a selection bias which means that the recruited participants are not representative of the population of the interest. Moreover, the reviewer stated that the authors failed to provide sufficient detail in participant recruitment process which reduce the replicability. The randomization process was also not included by the author which makes it difficult to know whether confounding variables were balanced at the baseline. Although this could increase the chance to introduce bias, the reviewer missed to point this out.

The major weakness of the design pointed out by the reviewer was the variability of the amount of practice in yoga. She stated that the variability in the dosage of yoga practice could have affected internal validity creating challenge in the process of interpreting the results. Moreover, the reviewer mentioned that information regarding the yoga intervention such as description for both at-home and in-person class yoga prescription was not sufficient enough to be replicated. However, the author clearly stated that audiotape/compact disks were provided to guide at-home daily yoga practice even though the contents in those materials were not provided. Overall, the research design (i.e. yoga intervention, internal and external validity) of the study was thoroughly analyzed.

            The reviewer mentioned that utilization of Functional Assessment of Cancer Therapy (FACT) to measure quality of life allowed to increase external validity and replication of the study. However, the FACT was one of the five measures used in this study. In addition to FACT, the Functional Assessment of Chronic Illness Therapy-Fatigue [test-retest reliability (r = .90), internal consistency (α = .94)], Functional Assessment of Chronic Illness Therapy-Spiritual [internal consistency (α = .87)], Distressed Mood Index (internal consistency .82 < α <.95) were used to measure limitations in daily activity and energy level, spiritual and existential well-being, and three domain of mood, respectively. The reviewer mentioned that the adherence was measured by recording attendance by the instructor. Other than adherence measure, all four measurement tools exhibits high reliability and internal consistency based on the information provided by the author. As mentioned by the reviewer, the psychometric properties were clearly mentioned and described and each instrumentations were appropriate to assess given constructs. As the reviewer pointed out, while the measurement instrumentation was appropriate, the scoring methods were not presented. The reviewer also mentioned that it is unclear whether the outcome measurers or the yoga instructor were trained or qualified. It could have been more informative if the reviewer included how this could have influenced the results of the study (e.g. increase level of random error). However, the reviewer missed report that the study did not blind the outcome measurers. Blinding/masking is important especially in this kind of study design (randomized controlled trial; RCT) to eliminate experimental bias

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